CMS’ Indirect Ask of Home Health Care Providers

Home health agencies today face a formidable challenge as CMS implements significant changes and proposes further reforms for the future. With reimbursement reductions and staffing shortages compounded by a rapidly growing senior population, agencies are compelled to reevaluate their care delivery models to ensure financial sustainability, operational efficiency, and desirable patient outcomes. CMS’ evolving perspective on care seems to indirectly demand that agencies adapt and align in order to thrive in the years ahead. Our mission is to support home health agencies in successfully navigating these changes and achieving long-term success in this evolving landscape.

To assist providers in better understanding the untapped potential of virtual care services and solutions, we highlight why embracing virtual care strategies can establish a cost-effective and outcome-focused care model while simultaneously improving clinician satisfaction and creating a competitive differentiator from others agencies in their market.

Managing the Balancing Act

Virtual care services pave the way for a balanced care delivery model that is patient-centric, profitable, and efficient. By incorporating virtual care programs, home health agencies can proactively set the stage for an efficient and profitable care delivery model, which will be essential as payers continue to roll out value-based care initiatives.

Decreasing Costs and Amplifying Operational Efficiency

Integrating a virtual care strategy can significantly reduce costs for home health agencies by replacing unnecessary in-home visits with virtual engagements, thus eliminating travel, staffing, and overhead costs that negatively impact profit margins and productivity models. By aligning virtual care with point-of-care delivery, agencies can enhance resource management and serve more patients with existing resources, increasing revenue and improving profit margins.

Amplify Clinician Satisfaction

Workforce satisfaction and retention are now more crucial than ever before for home health agencies. However, the transition from fee-for-service to value-based care has presented challenges for care team members who were accustomed to reimbursement models where quantity was prioritized over quality. Fortunately, virtual care services bridge the direct care gaps clinicians are concerned about during this transition. Virtual patient engagements and intuitive technology provide clinicians with the peace of mind needed to determine visit frequencies that reduce the financial challenges associated with visits where patient updates or education could be effectively addressed through a more cost- and time-effective approach.

Patient Engagement is Patient Satisfaction

Virtual engagements between routine visits offer a simple yet effective solution to actively involve patients in their care management. By reinforcing key aspects of care that contribute to quality outcomes and prevent hospital readmissions, home health agencies can enhance the overall patient care experience, leading to improved satisfaction scores. Leveraging the right virtual care technology, whether in-house or through outsourced services, enables seamless care coordination and collaboration among care teams. This streamlined distribution of updates and information ensures that patients see how well-informed their care teams are about their needs and are working together towards their care goals, fostering a heightened sense of care continuity.

Establish a Competitive Advantage

As the competitive landscape of the industry rages on, with consolidation and value-based care arrangements with referral networks, agencies should look for innovative ways to differentiate themselves from others in their market. Providers who implement strategic virtual care programs can take advantage of an early competitive edge that not only sounds good but is also backed by data-driven results. Virtual care will inevitably become the standard in the future, but forward-thinking agencies that take advantage of early adoption provide themselves a leg up on their competitors who are late to the party.

Integrating virtual care services into home healthcare brings numerous benefits. By utilizing virtual engagements, home health agencies can empower patients, promote active participation, and cultivate a patient-focused approach that improves outcomes and enhances the overall care experience. The time is ripe for agencies to embrace virtual care and position themselves as forward-thinking organizations capable of navigating changes without compromising patient care outcomes.

HHVBP Pre-Implementation Performance Report (PIPR) Available on iQIES.

Now that home health agencies have the fortunate (not so fortunate) requirement to participate in the Home Health Value-Based Purchasing (HHVBP) model, we’re sure you already know how crucial it is to keep a pulse on your agencies performance metrics.

That said, CMS’ Pre-Implementation Performance Report (PIPR) for the Expanded HHVBP Model is available for download from the Internet Quality Improvement Evaluation System (iQIES). This report provides valuable data on your agency’s HHVBP performance metrics, allowing you to identify areas where you can improve your performance and reimbursement.

To download your PIPR report through iQIES, follow the following simple steps provided by CMS:

  1. Log into iQIES at
  2. Select the My Reports option from the Reports.
  3. From the My Reports page, select the HHA Provider Preview Reports.
  4. Select the HHVBP file to view the report.

The PIPR report provides a national comparison of home health agencies within your cohort and a preview of where your agency’s performance may land relating to the baseline year of CY 2022. By reviewing the report, your agency can identify areas where care initiatives may be implemented or reassessed to provide an increased focus throughout the rest of year to improve performance areas. This report should be valuable in driving your final value-based purchasing (HHVBP) calculation and YoY potential payment.

While the HHVBP model is complex, and improving hospitalization and patient satisfaction measures can be challenging due to staff constraints, Telos Health Solutions’ Care Navigation program can assist with little to no friction on your staff. 

Our team has extensive experience implementing QAPI programs in home health and has helped numerous agencies implement a frictionless program aimed at their specific agency goals.  

Our Care Navigation program has helped our customers achieve several goals, and the best part is that it requires no additional effort from the clinical staff members of the agencies we work with. We handle patient engagement calls and provide updates on patient-reported information, and clinical staff members can act on these updates as they see fit/necessary

  • Reduce Acute Care Hospitalizations through early detection and education.
  • Reduce Emergent Care Use and identify frequent challenges.
  • Identify new fall incidents/provide fall prevention education assistance.
  • Identify new medication side effects/provide patient education assistance.
  • Identify new medication changes/provide patient education assistance.
  • Identify home safety roadblocks and provide proactive education assistance.
  • Identify patient-reported opportunities for care improvement/patient satisfaction and provide proactive virtual education assistance.

 If you want to learn more about how Telos can help or would like us to create a free strategic program implementation outline based on this report, find a time on the calendar below or call us at (972) 488-4029. 

Navigating the Perfect Home Health Storm

Do you keep an eye on the weather? When forecasts warn of blizzards or hurricanes, do you take necessary precautions? Just as society prepares for storms to minimize their impact, home health agencies must also brace for the industry’s “perfect storm”. 

While it is true that the convergence of various factors, such as a shortage of staff and a rapidly growing elderly population, is creating a perfect storm, it is important to acknowledge that these challenges also present an opportunity for growth and innovation. With the implementation of the Home Health Value-Based Purchasing (HHVBP) program and the rise of Medicare Advantage, home health care agencies are being called upon to adapt and innovate in order to provide the best care possible for their patients and reduce healthcare costs. Although navigating these challenges can and most likely will be daunting, the industry’s willingness to evolve and embrace change will undoubtedly lead to a brighter future for home health care.

Optimize Capacity and Forge Strong Partnerships

Agencies must optimize their capacity to manage referrals. Referral sources will partner with agencies that can handle volume while maintaining high-quality care and patient satisfaction. Every declined referral is an opportunity lost to competitors. Ensuring smooth patient transitions and reducing readmissions are critical for maintaining strong relationships with referral sources.

Prioritize Staff Satisfaction and Retention

Staff satisfaction should be a top priority for home health agencies. Dedicated, skilled staff are essential for navigating the storm successfully. Employees who feel supported in their day-to-day work are less likely to leave, and those with reasonable expectations placed on them provide better care to patients.

Implement Proactive Strategies

Just as it’s more productive to put plywood over windows or insulate pipes before a storm, it’s also beneficial for home health agencies to adopt proactive strategies. Implementing virtual care models, optimizing visit frequency, and utilizing real-time, actionable data can help agencies do more with less. This approach is especially important when dealing with Medicare Advantage plans, which often provide fewer visits but still impact HHVBP outcomes.

Lean Into Improving Care Coordination

Improving care coordination can be a daunting task, as limited time, staff, and communication barriers among systems can pose significant challenges. At Telos Health Solutions, we understand these obstacles and have created a comprehensive care navigation program to assist agencies in providing their patients with effective virtual engagement and touch-points delivered by home health trained clinicians. Our solution delivers real-time results, notifications, and feedback to all relevant parties, ensuring that everyone is informed when they need to be. By implementing our approach, agencies can enhance both patient and staff satisfaction, and better equip themselves for success in the face of industry challenges.

If you’re ready to lean more about how we are helping HHAs prepare for the VBP storm, use the meeting link below to schedule a call with us. 

Unlocking Future Success: 4 Opportunities that HHAs often overlook or undervalue.

As the landscape of home healthcare evolves, agencies face the challenge of delivering high-quality care while efficiently managing resources and expenses. Balancing these priorities requires strategic navigation, but there are proven approaches that can help agencies chart a course to success. By leveraging policy changes and technological advancements, owners and operators can implement tailored systems and strategies to achieve financial stability and prioritize patient care. With the right tools and mindset, agencies can thrive in this dynamic industry.

In this blog post, Nora Silver, RN, Director of Clinical Strategy and Initiatives at Telos, shares insights on four opportunities that she has observed as overlooked or undervalued through meeting with hundreds of home health agencies since joining Telos in August of 2022. 

Nora has 29 years of experience as a registered nurse and has worked in home health care for over 22 years. Before joining Telos, she served as an administrator of a home health, hospice, and palliative care organization for 12 years, overseeing a team that cared for an average of 450 patients per month.

1. Include the Patient’s Perspective in the Plan of Care

One of the most important things you can do to engage patients and caregivers in their care is to develop an individualized care plan. While the conditions of participation require patients and caregivers to provide input into their patient-specific plan of care, this should not be viewed as a mere regulatory obligation.

“When patients are able to provide their perspectives and input regarding their personal care goals, they feel valued and become more invested in their care, resulting in better engagement and satisfaction. Patients are also more likely to provide open feedback and seek out assistance before an exacerbation occurs,” says Nora.

In summary, when patients are actively involved in developing their plan of care, they gain a clearer understanding of their risk of hospitalization and the care objectives of receiving home health care services, leading to better outcomes and more efficient resource utilization.

2. Utilize Ranged Frequency and Patient-Specific Protocols

In 2020, CMS approved ranged frequencies, which allow agencies to incorporate patient-specific protocols to address exacerbations and optimize utilization. By providing visits at the frequency that the patient needs, regardless of the week of care, agencies can improve efficiency and capacity for staff. This can also positively impact patient and staff satisfaction and reduce costs per episode.

Agencies who strategically implement patient-specific protocols (not standing orders) for chronic illness can provide staff with needed interventions that prevent exacerbation, decrease readmission rates, and improve patient and staff satisfaction. 

“Maintaining patient care at home can be challenging for home health (HH) clinicians, as they rely on responsive physicians to give in-the-moment intervention orders. However, if clinicians set up patient-specific protocols with physicians at the beginning of care, in-the-moment contact becomes a simple notification rather than a request for intervention. This can be a game-changer for everyone involved,” explains Nora.

Additionally, Referral sources should have higher satisfaction as they’ll see decreased phone calls needing urgent guidance that could have been avoided if patient-specific protocols were utilized. 

3. Integrate Value-add Services that are Frictionless(ish) 

Outsourcing services can be a game-changer for home health agencies, but it’s important to choose options that can work with your agency’s existing technical solutions, don’t amplify your staffs workload, and integrate into your day-to-day operations frictionless(ish). Some examples of these value-add services include OASIS review and coding, revenue cycle management, pre-claim review, and virtual care. 

“As the administrator of a home health, hospice, palliative care, and DMEPOS for 12 years, one of the most difficult operational decisions I faced was outsourcing OASIS review and coding. However, we found an outstanding partner in Jnon Griffin and SimiTree, and the decisions turned out to be one of the best decisions I made for the organization” says Nora Silver.

By utilizing outsourced services, Nora was able reduce administrative tasks, access industry experts, strategically redistribute resources, and reduce costs. 

4. Drive Outcomes with Actionable Data

The reliance on OASIS data and clinician documentation at closed episodes can lead to significant shortcomings for home health agencies aiming to take a proactive approach to care and operations. Moreover, clinician documentation is often delayed and potentially critical information is buried in the visit notes, requiring additional manual work. 

To this end, virtual patient care and engagement solutions, such as Telos’ Care Navigation program, can be a highly beneficial way to access actionable information. With Telos, agencies can select specific patients to enroll, customize alerts, and provide patients with additional weekly touch points, ensuring that they are constantly collecting relevant data that is up-to-date and reflects the patient’s perception of their current care progression. By incorporating patient-reported data into their operations, home health agencies can deliver high-quality care, improve outcomes, and enhance patient and staff satisfaction while being cost-effective.

“Access to actionable information reported directly from patients throughout episodes of care, between OASIS assessments, is a game-changing opportunity for the home health industry. It enables HHAs to establish a constant feedback loop, allowing for quick adjustments when necessary and empowering care teams to drive agency initiatives,” notes Nora.


While home health agencies certainly face their share of challenges, there are strategic opportunities available for savvy agencies to seize. By effectively engaging patients and caregivers, optimizing resource utilization, and reducing costs per episode, agencies can drive better outcomes while keeping patients and staff happy.

Whether you’re interested in learning more about Nora’s experience implementing these opportunities as a home health administrator, or you want to explore what Telos is doing to help home health agencies achieve better outcomes, we’d love to hear from you. To schedule an introductory meeting at a time that works best for your schedule, simply send Nora an email at [email protected] or use the calendar below.

Let’s work together to improve patient care!

Breaking Through Barriers: Customized Virtual Care Solutions for Home Health Care Agencies

The advent of virtual healthcare has brought about a host of benefits, such as greater convenience, improved accessibility, and better patient outcomes. However, the transition from traditional in-person care to virtual care is not without its challenges. In particular, the home health space faces unique technical and operational barriers that make the adoption of cookie-cutter or fee for service virtual/digital health solutions  difficult.

In this blog, we explore two reasons why digital health solutions have struggled to gain adoption across the home health industry.  

1. Technical Challenges

One of the primary challenges of virtual healthcare is technical difficulties. Patients who receive care at home may encounter issues such as poor internet connection, lack of familiarity with new software platforms, and incompatible devices. These obstacles can disrupt the continuity of care, cause delays, and create frustration for both patients and providers.

For home health providers, these technical difficulties can be especially problematic. They serve a growing patient population who are usually of higher acuity with a workforce that has minimal bandwidth. Many virtual health solutions on the market require point-of-care clinicians to undergo new training to understand the virtual solution and support their patients with equipment like tablets effectively. For anyone who has dealt with utilizing various devices in a patients home, the challenge is not a matter of “if” technical issues will happen, but “when.” As staffing and resource challenges persist, agencies prioritize clinician satisfaction and reducing employee turnover,  causing owners and operators to become even more hesitant about implementing virtual/digital care solutions because they fear it will add more responsibilities to their teams.

2. Operational Challenges

Another significant barrier to the adoption of digital health solutions revolves around operational and workflow challenges. Home health providers have unique workflows, and incorporating new technologies into these workflows can be disruptive and time-consuming. 

Many solutions require significant administrative and care team effort, which can take resources away from patient care. Solutions that put an increased load on point-of-care teams, such as managing devices, troubleshooting technical issues, and educating patients, can amplify clinician burnout that limits adoption at scale.

A Solution that Fits

However, there are solutions available that are seamlessly integrated into daily workflows. Our solution is designed to capture relevant patient information between visits without any action required from the point of care teams. Our care navigators work alongside care teams to contact patients via phone calls, which originate from the agency’s main phone line. This approach provides care teams with additional patient information without disrupting their workflow or adding responsibilities. Patients can easily recognize and trust the calls, as they are made directly from the agency’s phone number. Our solution helps overcome many of the technical and operational hurdles to assist care teams in delivering uninterrupted quality care to the patients they serve.


While virtual healthcare has brought about a host of benefits, the home health space faces unique challenges that require tailored solutions.  Digital and virtual health solutions designed around fee-for-service models may not be the best fit for this space, given the technical and operational challenges faced by home health providers. However, there are solutions available that are integrated into existing workflows and allow point-of-care teams to provide high-quality care without added responsibilities. By understanding the challenges and seeking solutions that fit, home health providers can leverage the benefits of virtual healthcare to improve patient outcomes.

How Centralized Communication Improves Care and Satisfaction

A centralized communication channel is an essential tool for home health providers to effectively manage care and reduce costs.

By implementing a central point of contact for patients and equipping clinical managers and field clinicians with streamlined processes, agencies can improve continuity of care and increase efficiency.

One major challenge that home health agencies face is lack of coordination among stakeholders, which can impede the ability to proactively address routine issues for both patients and clinicians.

A solution to this problem is to have one central number for patients to receive calls from and call when in need of help. This ensures that all patient contact is directed through a single point of contact (the preferred phone number), rather than through multiple channels (various different phone numbers), making it easier to prevent unnecessary trips to the emergency room. Furthermore, it allows administrators and clinical managers to more easily evaluate and update internal processes to meet their agency’s needs.

Another challenge is that patients often reach out to clinicians at their personal or work numbers, even when they are not on the clock. By providing patients with a central number that all care team members use, it increases the likelihood that patients will answer calls and confirm scheduled visits, and it improves the chances that patients will contact that number when they need assistance. This eliminates the possibility of patients reaching out to a care team member who is unable to assist because they are with another patient or are off-duty.

In summary, a centralized communication channel solves two problems for home health providers:

  1. It improves coordination among stakeholders and ensures that patients have a single point of contact for all their needs,
  2. It allows clinicians to better manage their time and ensure that patients can reach someone when in need of assistance.

3 Crucial Reasons Agencies Constantly Optimize Operational Efficiency.

In Q4 of 2022 we met with 200+ home health agencies and compiled notes on why agencies are constantly seeking out new ways to optimize operational efficiency.  We found that most of the organizations who place efficiency improvement as a never ending goal do so for a 3 key reasons. 

  • Reduce costs: A strong belief in streamlining processes and eliminating unnecessary steps or activities of yesterday’s home healthcare norms lowers expenses, increases overall profitability, and reduces field clinician attrition. The ability to measure various operational efficiency metrics and covert those metrics into a financial impact model was something most wished they had as they believed it could help significantly drive change/adoption across different stakeholders. 
  • Improve patient care: By implementing more efficient ways to deliver care and manage outcomes, home health clinical managers and field clinicians are able to take a focused approach to ensuring each patients receive the best possible care on time, ultimately improving patient outcomes and satisfaction scores that make up a large part of value-based purchasing scores. 
  • Stay competitive: In the highly competitive home health industry, they believe it is essential to stay ahead of the curve and offer the best possible services to patients. By constantly seeking out ways to improve operational efficiency, home health agencies remain competitive and increase referral source satisfaction mostly due to their ability to retain a higher-than-average referral conversion rate while delivering quality care that achieves desired results.  

In conclusion, streamlining workflow processes for clinical and clerical staff is key to optimizing operational efficiency. This can be achieved through adopting new technology, collaborating with other agencies and outsourced service providers, or adjusting policies to better fit the current state of the organization. By implementing these strategies, home health agencies will be better equipped to serve their patients and staff in 2023 and beyond.